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Hi, this is Chiha li reporting for RheumNow on APLAR 2026, which was held in Seoul, South Korea.
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So I'm going to talk about deprescribing in RA, which is one of my favorite topics, because I'm really interested in optimizing medication — which
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means on one hand we should identify who to start, when, and what medicine, but given the risk-benefit inherent in our medications and treatment, I
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think ongoing assessment is important.
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And so for those select people who can, deprescribing offers an opportunity for optimization.
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So there were two posters that looked at this — one from a Japanese study and one from a Korean study.
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I want to first preface, though, by saying that deprescribing is not the same as drug withdrawal.
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Withdrawal is simply stopping a drug, or withdrawal of care.
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Deprescribing is different. It's a planned, supervised, deliberate approach to optimize the benefit-harms of treatment, and it's especially important for our rheumatic patient population who are getting older and thus more prone to the negative effects such as serious infection.
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And deprescribing can take many forms — it can involve dosing changes or dose reduction, spacing out intervals, and gradually tapering off if it's acceptable and tolerated by our patients.
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So let's first talk about the first poster.
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This is a sub-analysis of the SORAIO trial — that's S-O-R-A-I-O.
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It's poster number 2204 for those of you interested in looking this up on the APLAR platform, and it's a study from Keio University in Japan.
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For this one, patients in remission or low disease activity on ozoralizumab plus methotrexate were randomized — and this is a newer generation of anti-TNF — to see whether they could reduce the methotrexate, or just continue, or space out the anti-TNF itself.
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I like it because our ACR guidelines recommend deprescribing, and in geriatrics the prevailing thought is that deprescribing should be part of the conversation with new drug initiation.
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So the fact that they are doing trials on newer anti-TNFs I think is really encouraging and really embodies this idea.
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So the trial itself did not show non-inferiority for tapering.
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About 79% and 73% kept low disease activity after tapering anti-TNF and methotrexate respectively.
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But when you compare that to those who continued treatment, 98% were there.
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So the endpoint was not met. But in this follow-up study, they asked the question: okay, so most patients who tapered did fine — so then the real question is, who should be the one selected to taper?
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And the answer was baseline CDAI — meaning better disease control at time of deprescribing.
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A CDAI of 3.75 or lower predicted keeping low disease activity after taper, and actually a CDAI of 2.85 by the start of tapering predicted better likelihood of remission.
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Higher serum albumin interestingly was another predictor, although the premises and the justification behind that were not part of the poster.
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For methotrexate, compared to the biologics, the outcomes were better there — about 50% were able to be methotrexate-free — and there the only predictor was the starting methotrexate dose.
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The second poster, by a Korean group, asks a similar question.
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This is from the KOBIO registry. It follows 684 patients with DAS28 in remission for at least a year — and this is in contrast to guidelines where they recommend at least 6 months of remission, so these patients were in remission for longer at the start.
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They compared dose maintenance with dose reduction, and about half had a flare.
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This is consistent with any kind of trial that involves tapering or deprescribing with our biologic studies.
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What was interesting in their analysis: they found that the dose reduction itself was not associated with flare.
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However, what was associated with flare was their baseline disease activity score, and also whether they were on concomitant conventional csDMARDs along with the biologics.
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So those with methotrexate or any other csDMARDs on board with the biologics — when that was tapered, they did better.
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Also steroid dose: again, those who were on a lower dose did better.
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Overall speaking, we really should select for patients who are in deep remission.
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So why does this matter? As I said, our patients are getting older, and older adults are more vulnerable to side effects of biologic treatment, including serious infection.
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And it's important for us to continuously assess risk-benefit-harms and to know what the right patient population is to potentially consider reducing medication in.
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I will say, to be fair, both posters did not measure serious infection outcomes or even cost-effectiveness, although that could be another reason to consider this — but it is available in the wider literature.
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A couple of caveats: as I said, the trial itself missed non-inferiority, so it's not to say that this is better over continuing treatment.
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Our recommendations from ACR and EULAR are both conditionally recommending to continue treatment.
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But for those who are selected, and especially as we move more towards shared decision-making and patient preference, it's something to consider in select patients.
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And with disease remission being important, these two studies use clinical disease activity measures.
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But I think we should also consider the immunologic basis of remission and also radiographic remission to better identify patients who may benefit from this.
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Thank you for listening. This is Chihali for RheumNow, reporting from APLAR 2026.
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